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The Main Topics at the Oncoplastic Breast Surgery Course and Expert Panel.

ABSTRACT

The Oncoplastic and Reconstructive Breast Surgery course was held in Izmir by the Izmir Breast Diseases Federation in collaboration with the Breast Diseases Federation of Turkey. The techniques of oncoplasty, the application details and experience in this subject were shared. In this text, the main topics and outcomes are briefly summarised. These evaluations can be considered highly valuable on both local and regional scales.

Keywords: Oncoplastic breast surgery, quadrantectomy (surgery for breast cancer based on tumour location), breast surgery

Introduction

The 3rd Oncoplastic and Reconstructive Breast Surgery Course was organized by the Izmir Breast Diseases Association on May 21, 2016 in co-operation with the Association of Breast Diseases Federation of Turkey. Eighty seven speakers and the participants from 17 different cities deliberated on the issue during a full-day course between 8:30 and 18:30. Experienced specialists demonstrated their own approaches with a plethora of visual material (photos, videos etc.). Participants included Mustafa Emiroglu, M. Kemal Atahan (Izmir), Bekir Kuru (Samsun), M. Ali Gulcelik (Ankara), Atakan Sezer (Edirne) as the board directors of the course and Bahadir Gulluoglu (Istanbul) as the course consultant. Oncoplastic techniques, methods and experience in breast cancer surgery were described in detail. The main topics and messages are summarized briefly in this paper, and the assessment made on this subject Turkey is considered to be an important local and regional scale.

The status and development of oncoplastic and reconstructive breast surgery in the world and Turkey in relation to surgeons who have been working on this issue were explained briefly. Practices carried out in Turkey are almost parallel to the developments in the world. In this regard, the experience and practices about this issue must be shared with a wider community via literature. It was stressed that multi-centre studies on oncoplastic breast surgery were needed. A consensus was achieved on the requirement for general certification programs in this area to be formed by a commission planned to be constituted by oncoplastic and reconstructive surgeons among general surgeons and plastic surgeons. The importance of all aspects of the oncoplastic and reconstructive breast surgery (ORBS) was highlighted. Please see the Table 1 for details of the evaluation of oncoplastic breast surgery.

Oncoplastic breast surgery

Breast cancer surgery made progress within the last century from radical mastectomy to oncoplastic breast surgery. In 1980s, MCS revolutionized the field. In 2000s, oncoplastic breast surgery (OBS) was announced as an innovation in breast surgery. In fact, breast cancer surgery treatment is available in most of the cases in the form of standard breast aesthetics incisions without the need for oncoplastic techniques. However, one out of 4-5 patients had to undergo an aesthetical oncoplastic procedure after MCS. Therefore, surgical planning in addition to an overall assessment has gained a great deal of importance. Advanced planning before surgery is considered to be skipped by surgeons most of the time. Loss of breast tissue by more than 20% (loss of inner quadrants 10%) can lead to aesthetic problems. The importance of oncoplastic techniques are emphasised for future use. The application of these techniques simultaneously applied with lumpectomy ensures higher patient satisfaction and increases the quality of life. The simultaneous procedures were specifically discussed with high emphasis during the course.

Oncoplastic incisions are intended to prevent any defects after breast surgery. Up until recent years, it has been believed that incisions placed in parallel on both sides of maximum remaining skin tension lines (Kraissl's lines) and in the same orientation as collagen fibres (Langer's lines) are the most suitable incisions.

However, Aronowittz curvilinear horizontal incisions cause tension on the breasts, prevent the enlargement of the breast skin, and cause the breast tissue to collapse in certain areas while polarising upper quadrant, and so is considered as an outdated method in recent years. The radial incisions following the growth lines of the breast are thought to be more beneficial than the former method. In addition, it was noted that the Batwing and Benelli incisions were suitable for Langer and Kraissl lines; tennis racket in upper-out quadrant, vertical and reverse T in low-in quadrant; and radial rotation flap incision in inner quadrants are also suitable for the tension lines of the breast as defined by Aronowitz.

Speakers said that the glandular and dermoglandular flap techniques should be used widely and the area of lumpectomy should be filled in a way that prevents the development of seroma. The traditional way of waiting until the lumpectomy area filling with seroma is found outdated and abandoned. These techniques should be applicable in all the quadrants of the breast especially in the upper breast.

Oncoplastic breast surgery is not a standard approach; it can be modified for each patient in various ways. Sometimes, an open surgical area is found to be an interesting and creative technique. Thoracodorsal and/or epigastric tissue volume filling techniques are recommended for any possible defects in the external quadrants.

It was emphasized that vertical mastopexy had become very popular in breast reduction surgery in recent years. Lumpectomy and oncoplastic surgery could be done in various quadrants of the breast with this technique. It is recommended for the cases in which the volume of the breast is less than 1200 cc._

Application of the Grisotti flaps is recommended in the central tumors where it is necessary to remove the areola and head of the breast for security. And the benefits of Grisotti flap were underlined. The importance and facilitations of implementing of Benelli mastopexy were assessed in medium-volume and droopy breasts.

Breast volume and the tumor-to-breast-volume ratio are mostly debated in breast surgery. Therefore, it is highlighted in this course that the volume of breast should be measured. Oncoplastic breast reduction is defined as the oncoplastic breast surgery technique that is frequently applied in the world and in Turkey. Issues of dose distribution in radiotherapy, aesthetic issues after treatments and macromastia could be resolved surgically with a single operation by this technique. It is a major surgical operation with a significant learning curve. It should not be attempted without full knowledge of at least 5 to 6 techniques. It is highlighted that this technique brings extremely high patient-satisfaction when applied as a two-sided technique.

The endoscopic breast surgery was described in detail by its sole representative in Turkey. This operation is applied in breasts that are droopy and not very big. This technique inspires hope for surgery in the medium and long terms, although it was underlined that there was a significant learning curve during the course.

Breast reconstruction techniques

Although latissimus dorsi (LD) muscle flap lost its popularity due to the high morbidity rates, it is still in use for the patients with small breasts in Turkey as an operation of out-quadrant tumours either on its own or in combination with silicone implants. It is highlighted that we should recommend a new breast construction after mastectomy. The transverse rectus abdominus myocutaneous flap (TRAM) technique can be applied in patients that have adequate abdominal tissue. It is stressed that this technique is a major surgical operation with a significant learning curve. The patients found this technique to be more comfortable in the medium and long terms.

The participating breast surgeons discussed the silicone implant applications performed simultaneously with mastectomy. In recent years, mastectomy rates have increased in breast cancer treatment and reconstruction applications are also performed simultaneously. Silicone implant usage is increased rapidly due to the surgeons' and patients' comfort and ease-of-use of these implants. The protection of the lower breast fold affects the implant application positively and brings about aesthetic results.

A careful marking of the tumor bed is recommended for radiotherapy in oncoplastic breast surgery. In this regard, it is important to co-operate with the radiation oncologist. In recent years, reconstruction techniques applied simultaneously with mastectomy have become more and more popular. There is now a stronger opinion about the application of silicone before radiotherapy. It is specified that the complications of oncoplastic and reconstructive breast surgery do not create serious oncologic problems. They do not delay the adjuvant therapy. In the event of a positive assessment of the pathological border, re-excision can be done.

The highlights in the oncoplastic approach panel according to the breast quadrants

Multi-disciplinary assessment including the plastic surgeon is recommended in the treatment of breast cancer. The importance of the patient, breast, tumor features and the experience of the surgeon were discussed in relation to the implementation of these techniques. The importance of assessment before surgery was underlined by all the panelists. Who should perform these techniques? The importance of and the need for certification training s were emphasized especially in the discussion section. In this context, the situation in Turkey was discussed in detail and the efforts made towards new developments were distinguished, as well. Breast surgeons that attended and completed the courses can perform these operations.

Some of the speakers on the panel suggested that mastectomy and OBS should be differentiated from each other. Breast surgery technique selection constituted an important section of the panel discussions. OBS recommendations of the experts participating in the panel are summarized in Table 2. Table 3 shows the panelists, speakers and presidents of the sessions.

Discussion and Conclusion

ORBS techniques demonstrate a significant growth in Turkey. Also, training and certification are very important in ORBS. We should offer patients breasts without defects, not excellent breasts. If the patients do not have very high expectations, it will increase their compliance after surgery OBS is an approach that treats the patient, not the disease. OBS increases the role of surgeons. There are important efforts concentrated on learning and the implementation of these techniques among surgeons.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - M.E.; Design - B.K., M.E.; Supervision - B.G.; Funding - C.K.; Analysis and/or Interpretation - M.A.G., K.A., A.S.; Literature Review - M.E.; Writing - M.E.; Critical Review - B.G.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

Mustafa Emiroglu (1), Bekir Kuru (2), Mehmet Ali Gulcelik (3), M. Kemal Atahan (4), Atakan Y. Sezer (5), Cem Karaali (1), Bahadir Gulluoglu (6)

(1) Clinic of General Surgery, Izmir Tepecik Training and Research Hospital, Izmir, Turkey

(2) Department of General Surgery, Ondokuz Mayis University School of Medicine, Samsun, Turkey

(3) Clinic of General Surgery, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey

(4) Clinic of General Surgery, Izmir Ataturk Training and Research Hospital, Izmir, Turkey

(5) Department of General Surgery, Trakya University School of Medicine, Edirne, Turkey

(6) Department of General Surgery, Marmara University School of Medicine, Istanbul, Turkey

Address for Correspondence :

Cem Karaali, e-mail: cemkaraali@gmail.com

Received: 04.06.2016

Accepted: 05.07.2016
Table 1. Checking the elements required for the ORBS

                            Before surgery

Patient         Age, height, weight, DM, DVT , smoking
                history, HT, BMI, donor site (chest--
                  abdominal wall and back), approach
                          to the other breast
Tumor          stage, biology, DCIS ([+ or -]), size, distance
                          to skin and nipple
Breast       Density, size, shape, ptosis, areola status,
         skin quality, assessment o f t h e o the r br ea s t,
                    possible breast defect analysis
Surgeon  Multidisciplinary assessment, photo, experience level

               Pre-operative               After surgery

Patient              -               Expectations, compliance,
                                           complications


Tumor    Pathological examination       Oncological results
         (limit the frozen slices)
Breast    To be drained, symmetry        Aesthetic results


Surgeon      Photo, experience      Photo, documentation, follow

HT: hypertension; DM: diabetes mellitus; BMI; body mass index; DCIS:
ductal carcinoma; ORBS: oncoplastic and reconstructive breast surgery

Table 2. The proposed oncoplastic techniques according to breast
quadrants

                              Small breast and medium
Location of the tumor        sized breast - droopy (-)

Upper-outer quadrant         Elliptical radial incision
                              Half bat incision (side)
                                Round block incision
                                  Racket incision
                                   Glandular flap
                             Lateral thoracodorsal Flap
                                         LD
                                        TRAM

Upper-middle and upper-
inner quadrant           Breast head circumference incision
                                 Crescent incision
                                  Batwing incision
                           Half-batwing incision (inside)
                                Round block incision
                                   Glandular flap
                               Parallelogram incision
                                   Rotation flap
                                         LD
Central area                        Round block
                                   Grisotti flap
                         Central triangular incision Total
                              excision-primary closure
                          Glandular, dermoglandular flaps
Lower-outer quadrant         Lateral thoracodorsal flap
                          Glandular, dermoglandular flaps
                              Thoraco- epigastric flap
                                        TRAM
Lower-inner quadrant           Inframammary incisions
                                Triangular incision
                              Dermoglandular incision
                             Volume filling techniques
                             (from thoracodorsal space)
Lower-middle quadrant              Rotation flap
                               Vertical OBS incisions
                                Triangular incision
                                Reverse- T incision

                                  Small breast and medium
Location of the tumor            sized breast - droopy (+)

Upper-outer quadrant         Circumference incision of nipple
                                Elliptical radial incision
                                 Half bat incision (side)
                                   Round block incision
                                      Racket incision
                                      Glandular flap
                                     Benelli mastopexy
                                   Lateral thoracic flap
                                            LD
Upper-middle and upper-
inner quadrant              Breast head circumference incision
                                     Crescent incision
                                     Batwing incision
                              Half-batwing incision (inside)
                                   Round block incision
                                      Glandular flap
                                     Benelli mastopexy
                                       Rotation flap

Central area                            Round block
                                          Benelli

                                       Grisotti flap

Lower-outer quadrant                    Round block
                              Glandular, dermoglandular flaps
                                   Mastopexy techniques
                         Volume filling techniques from chest wall
Lower-inner quadrant              Inframammary incisions
                                    Triangular incision
                                  Dermoglandular incision
                                 Volume filling techniques
                                (from thoracodorsal space)
Lower-middle quadrant                  Rotation flap
                                  Vertical OBS incisions
                                    Triangular incision
                                    Reverse- T incision


Location of the tumor            Big breast

Upper-outer quadrant     OBR (lower, double pedicle)
                         Elliptical radial incision
                              Batwing incision
                               Racket incision
                         Lateral thoracodorsal flap
                               Glandular flap



Upper-middle and upper-
inner quadrant           OBR (lower, double pedicle)
                              Crescent incision
                              Batwing incision
                               Glandular flap
                                Rotation flap




Central area                         OBR
                             Grisotti reduction



Lower-outer quadrant      OBR (upper, upper-inner,
                            upper-outer pedicle)
                         Lateral thoracodorsal flap

Lower-inner quadrant      OBR (upper, upper-inner,
                            upper-outer pedicle)
                            Dermoglandular flaps
                                Rotation flap

Lower-middle quadrant     OBR (upper, upper-middle,
                            upper-outer pedicle)
                           Vertical OBS incisions


OBS: oncoplastic breast surgery; OMR: oncoplastic breast reduction;
LD: Latissimus dorsi flap; TRAM: transverse rectus abdominis
myocutaneous flap

Table 3. Participants as speakers, panelists and chairpersons in the
ORBS meeting

Mustafa Emiroglu       Bekir Kuru       Kemal Atahan
     (Izmir)            (Samsun)           (Izmir)
Bahadir Gulluoglu     Atakan Sezer     M. Ali Gulcelik
   (Istanbul)           (Edirne)          (Ankara)
  Zafer Canturk       Serdar Ozbas      Serdar Saydam
    (Kocaeli)           (Ankara)           (Izmir)
Cihangir Ozaslan     M. Ali Kocdor       Lutfi Dogan
    (Ankara)            (Izmir)           (Ankara)
   Cem Karaali         Hedef Ozun       Teoman Coskun
     (Izmir)            (Aydin)           (Manisa)
  Serhan Tuncer     Gursel R. Soybir     Belma Kocer
    (Ankara)           (Istanbul)         (Sakarya)
 Hasan Karanlik    Guldeniz Karadeniz   Levent Yeniay
   (Istanbul)         (Zonguldak)          (Izmir)
 Ercument Tarcan       Cem Yilmaz       Aykut Soyder
     (Izmir)           (Istanbul)          (Aydin)
Neslihan Cabioglu    Senem Alanyali     Murat Tuzuner
   (Istanbul)           (Izmir)            (Izmir)
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Title Annotation:Technical Article
Author:Emiroglu, Mustafa; Kuru, Bekir; Gulcelik, Mehmet Ali; Atahan, M. Kemal; Sezer, Atakan Y.; Karaali, C
Publication:European Journal of Breast Health
Article Type:Report
Geographic Code:7TURK
Date:Jan 1, 2017
Words:2332
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